HospiMedica International March 2018 by Globetech

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CLINICAL NEWS

Vol.36 No.1 • 2-3/2018

LEADER DAILY CLINICAL NEWS

ISSN 0898-7270

Soft Colonoscopy Robot Could Transform Routine Screening new study describes how a prototype robotic probe that adapts to the colon’s anatomy could enable hospitals to perform screening colonoscopies without expert supervision. Developed at the University of Nebraska Lincoln (UNL, USA; www. unl.edu), the semi-autonomous colonoscopic robot uses a minimally invasive locomotion approach that takes advantage of longitudinal expansion of an inflatable latex tube in order to propel the robot’s tip along the colon. Similar to an inflating balloon, the tube adjusts itself and makes

Ultrasound Imaging Needle Offers Breakthrough in Cardiac Surgery nnovative all-optical pulse-echo ultrasound imaging allows visualization of cardiac tissue in real-time during minimally invasive heart surgery. Developed by researchers at University College London (UCL; United Kingdom; www.ucl.ac.uk) and Queen Mary, University of London (QMUL; United Kingdom; www.qmul.ac.uk), the all-optical broad-bandwidth ultrasound needle is based on photoacoustic excitation of a nanotube-polydimethylsiloxane composite coating on the distal end of a 300μm multi-mode optical fiber by a pulsed laser. Ultrasound interrogation is

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Imaging Software Analyzes Kidney Stone Composition

Wide-Angle Mammography Improves Biopsy Workflow

streamlined, semi-automated tool analyzes kidney stones instantly using a patient’s computerized tomography (CT) scans. The StoneChecker (Radstock, UK; www.stonechecker.com) software, based on the TexRAD (Cambridge, UK; www.texrad.com) algorithm, examines the physical attributes of a renal stone on noncontrast enhanced CT scan slices. The patented filtration-histogram CT Texture Analysis (CTTA) algorithm highlights coarse features, using histogram analysis to quantify

n advanced mammography system expands diagnostic options. Based on wide-angle high-definition breast tomosynthesis technology, the new system generates high-quality 3-D images, enabling more targeted and accurate biopsies at lower doses.

A Image: Courtesy of Siemens Healthineers

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Mobile CT Provides Real-Time Imaging At Point-of-Care

Industry News . . . . . . . . . 25 International Calendar . . 26

n innovative 16-slice computerized tomography (CT) scanner delivers high quality non-contrast CT, CT angiography, and CT perfusion scans at the point-of-care (POC).

News Update . . . . . . . . . . 6 Product News . . . . . . .6-10

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High-Definition Visualization System Assists Minimally Invasive Surgery state-of-the-art imaging tower provides real-time high-definition (HD) and 4K images for endoscopic minimally invasive surgery (MIS) procedures. The DePuy Synthes (West Chester, PA, USA; www.depuysynthes.com) PUREVUE Visualization System combines a broad portfolio of tower components, including an autoclavable camera head, a light source, an advanced image processer, intuitive touchscreen navigation, and a host of other image management solutions designed to provide surgeons with

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News Update . . . . . . . . . 12 Product News . . . . . 12-14

News Update . . . . . . . . . 16 Product News . . . . . .16-20

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Soft Colonoscopy Robot Could Transform Routine Screening cont’d from cover

makes its way into the colon as it expands out of a fixture placed in the anus. The robot creates less than 6 Newton of normal force at its tip when pressurized at 90 kPa, generating a maximum force of just 44.17 mmHg, significantly lower than the safe intraluminal human colonic pressure of 80 mmHg. The robot design inherently prevents loop formation in the colon, which is recognized as the main cause of post procedural pain in patients. In ex-vivo experiments, the robot successfully advanced 1.5 meters inside an excised curvilinear porcine colon with average speed of 28 mm/sec, traversing four 90-degree curves to reach the cecum in just 54.2 seconds, compared to 15.9 minutes using traditional colonoscopy, and a minimum of 4.9 minutes by an experienced colonoscopist. The study was published in the April 2017 issue of Journal of Medical Engineering & Technology.

“In traditional colonoscopy, the colonoscope deforms the colon; it’s really hard to navigate something inside the colon from outside the body. Our robot is self-propelling, selfsteering and it complies itself with the shape of the colon,” said lead author biomedical engineer Hossein Dehghani, PhD. “The proposed robotic approach allows physicians to concentrate mainly on the diagnosis, rather than the mechanics of the procedure.” Colonoscopy is the endoscopic examination of the colon and the distal part of the small bowel with a video or fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected lesions. Virtual

colonoscopy, which uses imagery reconstructed from computed tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is also possible, although it is not standard and still under investigation regarding its diagnostic abilities. Image: A colonoscopy robot that inflates like a balloon could improve patient satisfaction (Photo courtesy of Hossein Dehghani/ UNL).

Ultrasound Imaging Needle Offers Breakthrough in Cardiac Surgery cont’d from cover

via a high-finesse Fabry–Pérot cavity on an optical fiber, using a wavelength-tunable continuous-wave laser. The transducer is integrated within a custom inner trans-septal needle that included a metallic septum in order to acoustically isolate the two optical fibers. In an experimental swine model, the needle provided real-time views of cardiac tissue at depths of up to 2.5 centimeters, with an axial resolution of 64 m, successfully revealing the anatomical structures required to safely perform trans-septal crossing, including the right and left atrial walls, the right atrial appendage, and the limbus fossae ovalis. The researchers added that as the technology is compatible with magnetic resonance imaging (MRI), it may also be used for brain or fetal surgery, or for guiding epidural needles. The study was published on December 1, 2017, in Light: Science & Applications. “We now have real-time imaging that allows us to differentiate between tissues at a remarkable depth, helping to guide the highest risk moments of these procedures,” said lead author consultant cardiologist Malcolm Finlay, MD, of QMUL. “The optical ultrasound needle is perfect for procedures where there is a small tissue target that is hard to see during keyhole surgery using current methods, and missing it could have disastrous consequences.”

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High-Definition Visualization System Assists Minimally Invasive Surgery cont’d from cover

visualization tools across a wide range of MIS procedures, such as rotator cuff repair, subacromial decompression, shoulder instability, anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) repair, and more. PUREVUE is a system of sub-systems, comprised of capital equipment components, visualization system optics, and accessories, including: The PUREVUE camera control system, which combines a light source, image processer, and local image management into a compact device with proprietary image processing technology that delivers native 1080P HD real-time image acquisition, without upscaling. The PUREVUE camera head, with a proprietary sensor designed for endoscopy to help deliver native 1080P HD real-time image acquisition. High quality primary and secondary surgical displays featuring functional design elements, an adjustable swivel arm, easy access to component connections, smooth mobility, and integrated power supply. Wireless imaging provides real-time surgical video transmission to secondary surgical displays, with immunity to signal interference. A full-page medical grade digital color printer that reproduces images in full HD resolution with outstanding photo-realistic image quality, along with a USB 2.0 interface and fast printing time. “With Americans living longer and seeking shorter recovery times, the call for minimally

50-degree wide-angle high definition (HD) breast tomosynthesis system obtains more targeted, accurate biopsies at a lower dose. The Siemens Healthineers (Erlangen, Germany; www.healthcare.siemens.com) Mammomat Revelation mammography system provides healthcare providers with a HD breast biopsy solution that enables one-click targeting of suspicious areas with a +/- one mm accuracy. The 50-degree scan angle can provide extremely high-quality three-dimensional (3-D) images to increase diagnostic confidence and enable earlier detection of even subtle lesions. Mammomat Revelation also provides automated breast density measurements at the point of examination, enabling immediate, personalized risk stratification, facilitating supplemental imaging while the patient is still at the facility. As a result, patients receive results faster, minimizing uncertainty and stress. Mammomat Revelation also offers the InSpect integrated specimen imaging tool, which allows biopsy samples to be rapidly imaged and visualized at the workstation, and the Titanium Contrast

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invasive procedures is accelerating,” said Stephanie Chamberlain, vice president and global platform leader at DePuy Synthes Mitek Sports Medicine. “We are committed to bringing forward innovation that responds to evolving patient needs, and the PUREVUE Visualization System is an example of how our advanced technologies enable high quality patient care.” Image: The PUREVUE Visualization System component tower cart (Photo courtesy of DePuy Synthes).

Wide-Angle Mammography Improves Biopsy Workflow

Enhanced Mammography (TiCEM) tool, a cost-effective alternative to MRI as an adjunct examination. “As tumor tissue can be difficult to distinguish from breast tissue, functional breast imaging with contrast enhanced mammography now expands the diagnostic options with the new system and improves patient access to functional imaging,” said Lars Hofmann, Head of Marketing for the X-Ray Products business line at Siemens Healthineers. “As discomfort is a key reason for a woman to avoid mammography exams we are improving their imaging experience with our Personalized Soft Compression.” In addition, smart automation tools and the MoodLight help soothe anxiety and put patients at ease, and the system also offers personalized soft compression (PSC), with which the breast compression process is softened and the compression force is automatically and individually adjusted. When coupled with the ergonomic SoftComp Paddles, PSC enables better breast positioning, more consistent image quality, and reduced patient discomfort.

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ISSN 0898-7270 Vol.36 No.1 • Published, under license, by Globetech Media LLC Copyright © 2018. All rights reserved. Reproduction in any form is forbidden without express permission. Teknopress Yayıncılık ve Ticaret Ltd. S¸ti. adına ˙Imtiyaz Sahibi: M. Geren • Yazı is¸leri Müdürü: Ersin Köklü Müs¸ ir Dervis¸ ˙Ibrahim Sok. 5/4, Esentepe, 34394 S¸is¸ li, ˙Istanbul P. K. 1, AVPIM, 34001 ˙Istanbul • E-mail: Teknopress@yahoo.com Baskı: Printkom Ltd. • İpkas Sanayi Sitesi 3. Etap C Blok • 34490 Başakşehir • İstanbul Yerel süreli yayındır. Yılda altı kere yayınlanır, ücretsiz dag˘ıtılır.

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Imaging Software Analyzes Kidney Stone Composition cont’d from cover

and assess distribution of grey-levels, coarseness, and regularity within the region of interest. Filters that extract and enhance image features at larger scales reduce noise artifacts, whilst heterogeneity in stone architecture is enhanced. Stonechecker then prepares a report of a stone’s given characteristics, such as volume, mean Hounsfield unit (HU) density, skin to stone distance, entropy, kurtosis, skew and other metrics. Each of these factors has been shown to be relevant in predicting stone-free rates and the potential outcome of a lithotripsy procedure carried out on the stone. Heterogeneity parameters at different spatial scales enable quantitative assessment of imaging biomarkers within the kidney stones, which can then be used to identify treatment failure on pre-treatment CT. “CTTA metrics reflect stone characteristics and composition and pre-

Mobile CT Provides Real-Time Imaging At Point-of-Care

dict ease of shock wave lithotripsy fragmentation. The strongest correlation with the number of shocks required to fragment a kidney stone is mean HU density and the entropy of the pixel distribution of the stone image,” reports the company. “With the aid of multiple linear regression analysis, the CTTA metrics of entropy and kurtosis can predict 92% of the outcome of number of shocks needed to fragment the stone.” Kidney stones are often no larger than a grain of rice, yet some can grow to a diameter of several centimeters, causing blockage of the ureters. If it cannot be dissolved chemically, the kidney stone is treated using extracorporeal shock-wave therapy or minimally invasive endoscopic modalities. Many of these patients

HospiMedica International February-March/2018

Image: CT texture metrics can identify kidney stone composition (Photo courtesy of StoneChecker).

PREMIER MULTIMEDIA PLATFORM SERVING THE WORLD’S HOSPITAL / MEDICAL COMMUNITY Anytime, Anywhere, On the Go... PRINT MAGAZINE

cont’d from cover

The new Samsung NeuroLogica (Danvers, MA, USA; www.samsung neurologica.com) OmniTom uses a combination of rapid scan time, an ultra-small footprint, and the advantage of immediate image viewing to make it an indispensable tool for collecting real time data on critically ill patients. OmniTom features an array of unique mobility features, including a small footprint and omnidirectional wheels to maximize maneuverability and allow easier and quieter movement in small spaces. In addition, OmniTom features an internal drive system, making portability less strenuous, while also offering smart-sensing collision avoidance software to maximize control and patient safety. An increased gantry opening of 40 cm allows improved coverage of the adult head and neck area, and fullbody pediatric scanning. The 16-slice (0.625 mm per slice) advanced data acquisition system offers effective dose optimization and highly advanced noise data acquisition system (NDAS) detectors which have been combined with a 24-bit processing chain that never compresses the data, leading to clearer images with ultimately low artificial noise. In addition, automatic exposure control (AEC) provides mA modulation during helical and axial scanning in order to regulate dose and image quality.

suffer from disease recurrence and need retreatment, but new stone formation might be reduced by adapting dietary habits or the use of particular medication strategies, as based on stone composition.

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ANESTHESIA MACHINE

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The BLR-2100 offers automatic warm-up and continuous self-test function during operation. Other features include visual and audible alarms and backup sensors, ceramic heaters with protecting grid, and dimmable halogen and LED light.

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Colorectal Cancer Develops Earlier Than Presumed new study suggests colorectal cancer (CRC) screening should begin at 45 years of age, so as to match rising mortality rates in young adults. Researchers at Clinique de Bercy (Charenton-lePont, France; www.bercy-cliniques-paris.fr) analyzed 6,027 colonoscopies in order to identify neoplasia, adenoma, and polyp detection rates and rank them according to age. The results revealed a 400% increase in neoplasia detection in patients aged 45 to 49, when compared to patients in the 40 to 44 age group. The researchers also found that the neoplasia detection rate was 8% higher in the 45 to 49 age group than in the 50 to 54 range. The mean number of polyps detected in the inner lining of the colon and adenoma detection rates also increased by 95.8% and 95.4% (respectively) between the 40 to 44 and 45 to 49 age groups. This was far more substantial than the increase between the 45 to 49 and the 50 to 54 age groups, which was 19.1% and 11.5%, respectively. The researchers therefore suggest that CRC screening begin at age 45. The study was presented at the 25th United European Gastroenterology (UEG) Week, held during October 2017 in Barcelona (Spain). “Even when patients with a familial and personal history of polyps or cancer are excluded from the findings, there is still a noticeable increase in detection rates in patients from the age of 45,” said lead author and study presenter David Karsenti, MD, of the digestive endoscopy unit. “The results of our research strongly indicate that screening for colorectal cancer should begin at the age of 45; this will help us to increase the early detection of colorectal cancer in young adults, and also enable the identification and safe removal of polyps that may become cancerous at a later date.”

CRC is the second most common cause of cancer-related death in Europe, killing 215,000 Europeans every year, with research showing that three in ten CRC diagnoses are now among those younger than 55. Despite strong evidence that screening for CRC reduces incidence and mortality rates, there are vast inequalities in CRC screening across Europe, with the vast majority of screening programs commencing between the ages of 50 and 55, with some not beginning until the age of 60. Image: A new study recommends that colorectal cancer screening should begin at 45 years (Photo courtesy of Getty Images).

Early Disease Detection Not Always Advantageous edical technology can today discover conditions and precursors of disease for which the treatment itself can be more traumatic than living with the ailment. Researchers at the Norwegian University of Science and Technology (NTNU; Trondheim, Norway; www.ntnu.edu) conducted a review of research literature dealing with early detection of diseases from the 19th century to the present. They found that 30 times as many articles about early detection are published today as in the 1950s, even when taking into account that the total number of publications has increased. In fact, most research articles look only at the beneficial aspects of early detection, and do not mention harms at all. Health checks and screening programs, improved diagnostic technology, innovations in bio-

markers, new m-health applications, and so called P4 (predictive, preventive, personalized, and participatory) medicine have increased this attention, with most articles sending the same message: early detection is a good thing. For example, they cite the Norwegian Directorate of Health, which recently decided that all pregnant women should be tested for gestational diabetes using a comprehensive and resource-intensive glucose tolerance test. While gestational diabetes has previously been screened for with a simple urine dipstick, the new method will label a lot more women as being at risk for diabetes, including many who perhaps don’t even have gestational diabetes. The study was published on May 5, 2017, in The BMJ. HospiMedica International February-March/2018

Capnography Sensors Reduce Adverse Outcomes During Sedation apnography monitoring during gastrointestinal endoscopic procedures (GEP) with procedural sedation is associated with significant reduction in the risk of rescue events and death. Researchers at NorthStar Anesthesia (Irving, TX, USA; www. northstaranesthesia.com), Springfield Regional Medical Center (OH, USA; www.mercy.com/springfield) and Medtronic (Dublin, Ireland; www.medtronic.com) conducted a retrospective data analysis of 258,262 inpatients and 3,807,151 outpatients undergoing GEP with sedation. Patients were clustered into four groups: pulse oximetry (SpO2) only; capnography only; SpO2 with capnography; and neither SpO2 nor capnography. Outcome measures were incidence of pharmacological rescue events – defined by administration of naloxone and/or flumazenil – and death. The results revealed that for inpatients, capnography monitoring was associated with a 47% estimated reduction in odds of death at discharge, and a non-significant 10% estimated reduction in the odds of pharmacological rescue event at discharge. For outpatients, capnography monitoring was associated with a 61% estimated reduction in the odds of pharmacological rescue event at discharge, and a non-significant 82% estimated reduction in the odds of death. The study was published on November 28, 2017, in BMC Anesthesiology. “The use of capnography during GEP with procedural sedation is associated with significant reductions in the risk of pharmacological rescue events in outpatients and death in inpatients,” concluded lead author Michael Jopling, MD, of NorthStar Anesthesia, and colleagues. “Despite the limitations of this retrospective data-based study, we believe the use of capnography during GEP performed with sedation should be recommended.” GEP such as esophagogastroduodenoscopy (EGD), endoscopic retro-

grade cholangiopancreatography (ERCP), and colonoscopy are standard procedures for the diagnosis and therapy of gastrointestinal disorders, but can be associated with discomfort. To improve patient comfort, the use of sedation in these procedures is common, but may result in druginduced airway obstruction, respiratory depression with hypoventilation, and hypoxemia. Using capnography to continuously monitor respiratory rate, end-tidal carbon dioxide (ETCO2) levels, and waveform pattern can allow for the near real-time assessment of ventilation. Image: A new study suggests capnography monitoring can reduce harm during gastrointestinal endoscopic procedures (Photo courtesy of Pisanieprac).

Cardiologist Care Reduces Incipient AF Mortality pecialist care associated is associated with a significantly lower death rate in patients newly diagnosed with atrial fibrillation (AF), according to a new study. Researchers at the University of Toronto (Canada; www. utoronto.ca), the Institute for Clinical Evaluative Sciences (ICES; Toronto, Canada; www.ices.on.ca), and other institutions conducted a retrospective study of adult patients with new-onset AF in Ontario (Canada) from 2010 to 2012, in order to assess the association between cardiologist care and clinical outcomes. Patients who saw a cardiologist within one year of initial diagnosis were matched to patients who did not. Main outcomes and measures included death, hospitalization for AF, stroke syndromes, bleeding, and heart failure. The results revealed that the majority (85%) of new-onset AF patients saw a cardiologist within the year. Cardiologist care within the first year of diagnosis was associated with a lower rate of death (5.3% versus 7.7%) than in those who did not seek care, despite increased hospitalizations for AF (17.9% versus 8.2%), stroke syndromes (1.7% versus 0.5%), bleeding (3.1% versus 2.0%), and heart failure (3.2% versus 1.4%). The results indicate that one in 15 patients with new-onset AF died within a year of the diagnosis. The study was published in the December 2017 issue of the Canadian Journal of Cardiology. “Variations in AF care across medical specialties are well known. Other than stroke prevention therapy, no other therapy has been associated with improved survival in patients with AF,” said lead author cardiologist Sheldon Singh, MD, of the University of Toronto. AF occurs when the heart’s two upper chambers beat erratically. In one form, paroxysmal AF, patients have bouts of erratic beats that begin spontaneously and usually last less than a week. It can lead to serious adverse events such as thrombi traveling from the heart to obstruct arteries supplying the brain, causing stroke, or other parts of the body causing tissue damage.

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The VT650 and VT900 gas flow analyzers include one-channel, full-range airflow functionality that streamlines testing. The all-in-one analyzers allow users to save time and avoid errors with customizable test profiles and data recording using on-board memory.

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Gelatin Accelerates Healing of Blood Brain Barrier new study shows that gelatin has a significant effect on the blood brain barrier (BBB) by promoting rapid restoration of integrity after injury. Researchers at Lund University (Sweden; www.lu.se) conducted a study involving sedated female rats to investigate how the brain is repaired after being subjected to an acute injury. Gelatin-coated needles were used to induce injury in the cortex cerebri in one group, and needles without gelatin in the other. Cellular and molecular markers were studied using quantitative immunohistochemical microscopy at acute (less than two hours, one day, and three days), intermediate (one to two weeks), and long-term time points (six weeks) following a transient insertion of the stainless steel needles. The results showed that injuries caused by the gelatin coated needles showed a significantly faster resolution of post-stab bleeding and leakage than non-coated controls, as well as differential effects on different groups of microglia cells. Neuronal populations and activated astrocytes were largely unaffected. The study was published on October 14, 2017, in Acta Biomaterialia. “Knowledge about the beneficial effects of gelatin could be significant for brain surgery, but also in the development of brain implants”,

said lead author Lucas Kumosa, PHD, of the Lund University Neuronano Research Centre (NRC). “The use of gelatin-coated needles reduced or eliminated the leakage of molecules (which normally don’t get through) through the blood brain barrier within twenty-four hours. Without gelatin, the leakage continued for up to three days.” “Gelatin is a protein and its decomposition releases amino-acids that we believe could promote the reconstruction of blood vessels and tissue,” said senior author professor of neurophysiology Jens Schouenborg, PhD. “Although the research field of brain electrodes is promising, it has been a challenge to find solutions that don’t damage the brain tissue. Knowledge of how injuries heal faster with gelatin could therefore be significant for the development of surgical treatment as well.” MMPs are a group of enzymes that in concert are responsible for the degradation of most extracellular matrix (ECM) proteins during organogenesis, growth, and normal tissue turnover. While expression and activity of MMPs in adult tissues is normally quite low, it increases significantly during some pathological conditions that lead to unwanted tissue destruction, such as inflammatory diseases, tumor growth, and metastasis.

Osteoporosis Screening Could Prevent Fractures in Elderly new study suggests that a systematic, community-based screening program in older women could be effective in reducing hip fractures. Researchers at the University of East Anglia (UEA; Norwich, United Kingdom; www.uea.ac.uk), the University of Sheffield (United Kingdom; www.sheffield.ac.uk), the University of Bristol (United Kingdom; www.bristol.ac.uk), and other institutions conducted a randomized controlled trial involving 12,483 women (70-85 years of age) in order to compare a screening program that used the Fracture Risk Assessment Tool (FRAX) with standard care. Participating women were recruited from 100 general practitioner practices in seven regions of the UK: Birmingham, Bristol, Manchester, Norwich, Sheffield, Southampton, and York. Women who were currently on prescription anti-osteoporotic drugs and any individuals deemed to be unsuitable to enter a research study were excluded from the study. In the screening group, treatment was recommended to women identified to be at high risk of hip fracture according to the FRAX 10-year hip fracture probability. The primary outcome was proportion of osteoporosis-related fractures over a five-year period, with secondary outcomes being proportions of subjects with at least one hip fracture, any clinical fracture, or mortality, and the effect of screening on anxiety and health-related quality of life. The results revealed that in the screening group, treatment was recom-

mended in 14% of 6,233 women. Use of osteoporosis medication was higher at the end of year one in the screening group (15%), as compared to controls (4%), with uptake particularly high in the screening high-risk sub-group. While screening did not reduce the primary outcome of incidence of all osteoporosis-related fractures, nor the overall incidence of all clinical fractures, it did reduce the incidence of hip fractures by 27%. There were no differences in mortality, anxiety levels, or quality of life. The study was published on December 15, 2017, in The Lancet. “A hip fracture can be devastating, with a loss of independence, and less than one third of patients make a full recovery. Mortality at one-year post-fracture is approximately 20%,” said lead author Professor Lee Shepstone, PhD, of UEA. “A community-screening approach based on the FRAX fracture risk tool is both feasible and effective. Given that the number of costly and debilitating hip fractures is expected to increase with an ageing population, the results of this study potentially have important public health implications.” “Low-cost screening with FRAX among the older population could result in effective, targeted intervention to reduce the human and socioeconomic burden of hip fractures,” concluded senior author Professor Eugene McCloskey, MD, of the University of Sheffield. “We estimate that the strategy could prevent up to 8,000 hip fractures per year in the UK. Even greater gains could be made if we could reach out to women similar to those who did not take part in the study.” HospiMedica International February-March/2018

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Critical Care

WhatsApp Speeds Up Heart Attack Treatment Time iagnostic electrocardiograms (ECGs) sent directly to hospital catheterization labs via WhatsApp (www.whatsapp.com) enable triaged patients to bypass the emergency department (ED), according to a new study. Researchers at Insituto Cardiovascular de Buenos Aires (ICBA; Argentina; www.icba.com.ar) and Sanatorio Anchorena (Buenos Aires, Argentina; www.sanatorio-anchorena.com.ar) conducted a study that prospectively enrolled 896 patients who underwent ST-segment elevation myocardial infarction (STEMI) between 2012 and 2016. Hospital admission occurred by three routes – patients arrived at the emergency department by their own means; ambulance delivered patients to the ED; and ambulance delivered patients to the catheterization (cath) lab, with the ED bypassed. In the third group, an ambulance doctor conducted an ECG on ar-

Intravenous Alteplase Raises Ischemic Stroke Survival new study also warns that ischemic stroke patients who do not receive intravenous (IV) alteplase are significantly less likely to survive. Researchers at Georgia State University (GSU; Atlanta, USA; www. gsu.edu), the Georgia Department of Public Health (Atlanta, USA; https://dph.georgia.gov), and other institutions reviewed the 2008–2013 Georgia Coverdell Acute Stroke Registry data, which was then linked with 2008–2013 hospital discharge records and 2008–2014 death data in the state of Georgia (USA). The aim of the study was to assess the impact of thrombolytic treatment by IV alteplase on one-year mortality and readmission rates among acute ischemic stroke patients. The results revealed that that 9,620 people underwent acute ischemic stroke during the study period. Of these, 20.3% of patients died and 22.4% were readmitted within the year. Analysis showed that patients who did not receive IV alteplase had a 49% higher risk of dying at one year than those who were treated with the thrombolytic agent. Among patients who were discharged, no statistically significant difference was documented in the odds of being readmitted at least once within 365 days of post-stroke discharge. The study was published on July 31, 2017, in the American Journal of Emergency Medicine. “Clinicians may be hesitant to administer IV alteplase because of concerns about the drug’s complications, which can include bleeding,” said lead author Moges Ido, MD, of GSU. “But this study indicates that unless major contraindications are present, patients should be offered this treatment as a life-saving measure.” IV alteplase administered within 4.5 hours of symptom onset is the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke. However, well-recognized limitations of this therapy include the narrow therapeutic time window and contraindications such as recent surgery, coagulation abnormalities, and a history of intracranial hemorrhage. Moreover, IV alteplase appears to be much less effective at opening proximal occlusions of the major intracranial arteries, which account for more than one-third of cases of acute anterior-circulation stroke.

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rival at the patient’s home or public place. If STEMI was the diagnosis, the ECG was transmitted via WhatsApp a cardiologist at the hospital to confirm diagnosis and prepare the cath lab. On arrival, patients were taken directly to the cath lab and did not stop in the ED. The researchers then compared treatment times and outcomes between all patient groups to determine if direct transfer to the cath lab led to quicker treatment, and to evaluate the impact of direct transfer on left ventricular ejection fraction (LVEF), length of hospital stay, and mortality. The results showed that the time between symptom onset and treatment was significantly lower in the Whatsapp group (150 minutes) than the other two groups (200 minutes). The overall mortality rate of all STEMI patients in the study was 2.23%, but mortality was significantly lower in the Whatsapp group (0.83%) than the other groups (3.17%). Patients in the Whatsapp group also had a shorter hospital stay (4.88 days versus 5.58 days), and better LVEF at discharge (51% versus 48%). The study was presented at the Argentine Congress of Cardiology (SAC), held during October 2017 in Buenos Aires (Argentina). “Patients have the best chance of survival when they receive primary angioplasty to restore blood flow to blocked arteries within 90 minutes of contacting the health service. Advanced notification enables hospital staff to prepare the cath lab, and the doctor is ready to start primary angioplasty when the patient arrives,” said lead author cardiologist Nicolás Lalor, MD, of ICBA and Sanatorio Anchorena. “Using WhatsApp on a smartphone is a cheap and easy way for ambulance and hospital doctors to communicate, and we will be rolling this procedure out to other hospitals in Argentina.” “This is a very easy way to improve the treatment of acute myocardial infarction in our country,” commented Alberto Fernández, MD, scientific program coordinator of SAC 2017. “Given the very long distances between centers that have percutaneous transluminal coronary angioplasty facilities, particularly in cities in the interior of the country, the opportunity to call the interventional cardiologist and prepare the cath lab could improve the prognosis of patients.” Alteplase is a recombinant tissue plasminogen activator (tPA) made by Genentech (San Francisco, CA, USA; www.gene.com), which is found in the human body as a serine protease on endothelial cells that line the blood vessels. As an enzyme, it catalyzes the conversion of plasminogen to plasmin, the major enzyme responsible for clot breakdown. Use of tPA is contraindicated in hemorrhagic stroke and head trauma.

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INFOTAINMENT TERMINAL

INFANT COOLING SYSTEM

Spencer Italia

ADVANTECH iHealthCare

Cincinnati Sub-Zero

The KWT offers safety protection to patients and operators, as well as enables smooth patient transfer operations. The raised positioning of the IV-support guarantees an obstaclefree working environment for patient treatment along with correct fluid dynamics.

The HIT-W183 features an Intel N4200 processor, dual operating systems and a widescreen display with PCAP 10-point touch control. It also features a 5MP camera, and a front panel that protects against water and dust ingress and can be cleaned easily.

The Kool-Kit Neonate has been designed with precision and accuracy, which are particularly important during the cooling, maintaining and re-warming stages of infants. It includes blanket, mittens, booties and esophageal/rectal temperature probe.

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Smart Intubation Device Monitors Intensive Care Patients novel parenteral feeding platform identifies gastric reflux, secretion, and urine outputs automatically, minimizing the likelihood of patient complications. The Art Medical (Even Yehuda, Israel; http://artmedical.com) smARTrack feeding tube system includes disposable sensor-enabled enteral feeding tubes that offer continuous monitoring of gastric reflux, saliva, and urine output, and a console-based dashboard that automatically alerts attending clinicians of any abnormalities. In addition, the smARTrack console is equipped with a motorized mechanism that automatically and in real-time stops working if the feeding tube moves out of position during ongoing use, and can guide an operator to correctly re-position the tube. SmARTrack feeding tubes are equipped with sensors designed to provide information on the location of the tube tip, relative to the lower esophageal sphincter (LES), thus assisting to reduce the incidence of misplacement during first positioning. It also monitors position continuously during the course of the feeding and automatically alerts care staff of tube migration. Along with watching for complications or infection, the smart feeding tubes can also help offset the common high rates of inaccurate calculation of a patient’s nutritional needs. “One of the challenges for the ICU staff is patients’ prolonged length of stay and mortality from complications which are unrelated to the original reason of hospitalization,” said Liron Elia, founder and CEO of Art Medical. “Aspiration of foreign materials is a major risk for intubated patients and technology is what is needed to solve this problem.” Tube related reflux and secretion may cause acute kidney injury (AKI), aspiration pneumonia (AP), and ventilator-associated pneumonia (VAP), serious complications that can lengthen hospital stays and even

be fatal. Currently, ICU nurses and doctors must monitor for such complications, but due to the constant nature of intubation, many time-sensitive abnormalities go unnoticed, resulting in high complication rates; 25% of ICU patients develop VAP, and nearly half of those patients never recover. Another 50% of patients who are admitted to an ICU and stay more than 24 hours end up with an AKI. Image: A sensor-based enteral feeding system can prevent life-threatening ICU complications (Photo courtesy of Art Medical).

Discreet Urinary Catheter Improves Quality of Life compact intermittent urinary catheter targets patients looking for a discreet, hygienic, and easy to use solution that fits seamlessly in their everyday life. The CompactCath (San Francisco, CA, USA; www.compactcath.com) intermittent urinary catheter is provided to patients in an unobtrusive, tightly coiled design in an opaque package that eliminates much of the inconvenience and embarrassment associated with self-catheterization. Features include pre-lubrication with silicone oil, fire-polished eyelets, and a non-touch insertion technique. CompactCath also includes a unique drainage control mechanism that gives catheter users more privacy, comfort, hygiene, and control. Once the patient needs to void, the packaging is opened and the catheter is released; as it is pulled out of the coil, the pre-lubricated

sheath slides along the catheter, lubricating its surface with silicon oil for smoother and more comfortable insertion. The eyelet and tip are then inserted into the body; once the tip reaches the bladder, the drainage spout is released by pushing down on the funnel. After use, the catheter is recoiled for discreet disposal. The unisex catheter is available in a variety of sizes for both pediatric and adult users. Intermittent catheterization is used to drain urine from a bladder that is not emptying adequately, or from a surgical channel connecting the bladder and the abdominal surface. It is advocated for patients with incomplete bladder emptying due to idiopathic or neurogenic bladder dysfunction. Benefits include reduced post-void residual urine, reduced intravesical bladder pressure, and fewer episodes of over-distention, all of which help preserve an adequate blood supply to the bladder wall and fewer infections. HospiMedica International February-March/2018

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Miniature Cardiac Implant Captures Heart Rhythm Data smartphone compatible insertable cardiac monitor (ICM) helps physicians and patients monitor abnormal heart rhythms remotely. The Abbott (Abbott Park, IL, USA; www.abbott.com) Confirm Rx ICM is a slim, discreet subcutaneous implant that continuously monitors a patient’s heart rhythm, providing powerful data to help monitor irregular heartbeats, unexplained syncope, palpitations, and suspected atrial fibrillation (AF). The rhythm data is proactively transmitted wirelessly to the myMerlin mobile app, which is available in over 35 languages. MyMerlin mobile also helps patients to record their symptoms on their own smartphone, as well as specify events such as fainting, or if they experience a fast heart rate. The Confirm Rx ICM limits communication to a single authenticated myMerlin mobile app, and all wireless communications are encrypted using the highest standards in mobile security. This allows patients to sync their data with their clinic at any time, and view their transmission history without having to contact their clinic to confirm successful data transfers. Patients can also get automatic alerts when they have missed a scheduled transmission, saving the clinic from having to follow up with the patient. “Confirm Rx shows what we can do with cutting edge communica-

Critical Care

Image: The world’s first smartphone-enabled and insertable cardiac monitor by Abbott

tion technology and the most advanced medical devices that provide new opportunities to improve patient care,” said Avi Fischer, MD, medical director of Abbott’s Cardiac Rhythm Management business. “By offering a device that uses Bluetooth wireless technology from the patient’s smartphone, we can help physicians easily and remotely diagnose potentially dangerous abnormal heart beats, without requiring the patient to use a separate or cumbersome recording device.” The Confirm Rx ICM system was developed by St. Jude Medical (SJM, St. Paul, MN, USA; www.sjm.com), which was acquired by Abbot in January 2017 for USD 25 billion with the intention of creating a premier medical device company. An extensive development pipeline is expected to deliver a steady stream of new medical devices across cardiovascular, diabetes, vision, and neuromodulation patient care.

Balanced Crystalloid Fluids Shown Safer than Saline mergency intravenous (IV) administration of balanced crystalloids reduces mortality and complications compared to saline, according to a new study. Researchers at Vanderbilt University Medical Center (VUMC, Nashville, TN, USA; www.mc.vanderbilt.edu) conducted two pragmatic, multiple-crossover trials to compare the effect of balanced crystalloids (Lactated Ringer’s or Plasma-Lyte A) in 29,149 adults treated in the emergency department (ED) and hospitalized outside an intensive care unit (ICU). IV fluid type was assigned on calendar month basis, with crossover between balanced crystalloids and saline each month during the 16-month trial. Main outcomes included hospital-free days and 30day major adverse kidney events (MAKE30). The results showed that the median fluid volume in the ED was 1.1 liters, and 88% of the patients exclusively receiving the assigned fluid. Compared with saline, treatment with balanced crystalloids resulted in

similar hospital free days, but a lower incidence of MAKE30 (4.7% versus 5.6%), which was manifest in reduced composite of death, new renal replacement therapy, and persistent renal dysfunction. The study was presented at the annual meeting of the American College of Chest Physicians (CHEST), held during October 2017 in Toronto (Canada). “These fluids are used every day and in millions of patients annually in the United States and worldwide. There is no functional cost difference between them, and now we have the data to show that [balanced crystalloid fluids] produce a better patient outcome,” said lead author pulmonologist Matthew Semler, MD. “It’s reasonable to consider changing practice; we’ve changed our practice, and are transitioning from primarily using saline to primarily balanced crystalloid.” Ringer’s lactate, also known as Hartmann’s solution, is a crystalloid mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure and for fluid resuscitation after blood loss due to trauma, surgery, or a burn injury.

Fructosamine Levels Help Assess Pre-Op Glycemic Control erum fructosamine could serve as an alternative to hemoglobin A1C (HbA1C) as a predictor of adverse surgical outcome in patients with diabetes or hyperglycemia, according to a new study. Researchers at Thomas Jefferson University (TJU; Philadelphia, PA, USA; www.jefferson.edu) and Tel Aviv University (Israel; www.tau.ac.il) conducted a study that screened 829 patients undergoing primary total joint arthroplasty using serum HbA1c, fructosamine, and blood glucose levels. All patients were followed, and total joint arthroplasty complications were evaluated, in particular surgical-site infection (SSI). Based on recommendations of the American Diabetes Association, an HbA1c level of 7% was chosen as indicative of poor glycemic control, which correlated with a fructosamine level of 292 mol/L. The results of the study revealed that high HbA1c levels did not predict increased risk of complications; high fructosamine levels, on the other hand, were associated with a greater risk for deep SSI infection, readmission, and reoperation. In addition, 35% of patients with fructosamine levels higher than the cut-off level of 292 mol/L had no history of diabetes, indicating an increased risk in patients who might not otherwise have been identified. The study was published on November 15, 2017, in The Journal of Bone & Joint Surgery.

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MUSCULOSKELETAL MRI

ULTRASOUND SYSTEM

Radcal

Esaote

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The Accu-Gold Touch instruments incorporate the largest touch screen in the industry to make diagnostic x-ray QA even faster and easier. The series also provides access to the full lineup of Accu-Gold sensors, the most extensive line of x-ray QA sensors available.

The S-scan is a complete musculoskeletal MRI that uses eXP Technology to cover all musculoskeletal anatomy. Featuring a maintenance-free open permanent magnet with 0.25T field strength, the system can be installed in a single room of 18 square meters.

The Apogee 3500 Elite features versatile solutions and user-friendly workflow to ensure professional diagnosis. It uses MFI to reduce signal distortion and eliminate unwanted noises for rendering premium images with outstanding resolution and high contrast.

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Extremity CBCT System Reduces Metal Artifacts compact cone beam computerized tomography (CBCT) system that can image extremities at the point of care (POC) now offers advanced metal artifact reduction software. The Carestream (Rochester, NY, USA; www.carestream.com) OnSight 3D Extremity System is designed to capture high-quality three dimensional (3D) images at the POC via an easily accessible open bore that allows both upper and lower extremity screening, including weight-bearing studies that are not possible with traditional CT. System features include large field isotropic images that can reveal subtle or occult fractures; reduced doses compared to conventional CT systems; image acquisition of the extremity in a single 25-second rotation; and a small footprint and simplified design that cut time and cost of system installation. An optional software upgrade offers advanced metal and scatters correction algorithms and reduced noise uses iterative reconstruction techniques from the original scan in order to eliminate the need for additional imaging studies; image processing can be easily adjusted and optimized according to the amount of metal present via an intuitive touch screen interface. For added flexibility, the metal artifact reduction software can be activated prior to the scan or may be applied after the original reconstruction is complete. “Carestream’s second generation of software takes our state-of-the-art original metal reduction software to a new level,” said Helen Titus, worldwide marketing director for ultrasound and CT at Carestream. “It provides enhanced flexibility, depending on the metal content present and reduces the visual distortion caused by screws, implants, rods, and other metal objects to create improved visibility and diagnostic confidence.” During CBCT, the region of interest is centered in the field of view.

A single 200-degree rotation acquires a volumetric data set used to produce a digital volume composed of 3D voxels of the anatomical data, which can then be manipulated and visualized. CBCT has recently become more practical thanks to the introduction of large-area high-speed digital X-ray imagers, such as hydrogenated amorphous silicon (aSi:H) based flat-panel detectors. Image: A knee being imaged with the OnSight 3D extremity system (Photo courtesy of Carestream Health).

X-Ray Algorithm May Reduce Radiation Doses by Thousands-Fold -ray phase-contrast imaging (PCI) can improve the visibility of soft tissues by an order of magnitude or more compared to conventional radiographs, according to a new study. Researchers at Monash University (Melbourne, Australia; www. monash.edu.au), the Japan Synchrotron Radiation Research Institute (JASRI; Sayo, Japan; www.spring8.or.jp), and other institutions attempted to enhance image contrast by using phase shifts (refraction) of X-rays to increase signal-to-noise ratio (SNR) by up to two orders of magnitude – compared to conventional computerized tomography (CT) at the same radiation dose – and without loss of image quality. The results revealed that as radiation dose decreases, the relative improvement in SNR increases. The researchers found that the enhancement can be traded for a reduction in dose greater than the square of the gain in SNR. Thus, reducing the dose by 300 fold resulted in the phase-retrieved SNR that was still al-

most 10 times larger than the absorption contrast data. According to the researchers, the potential for dose reduction factors in the tens of thousands without loss in image quality is possible, which would have a profound impact on medical and industrial imaging applications. The study was published on November 21, 2017, in Nature Scientific Reports. PCI is a general term for technical methods that use information concerning changes in the phase of an X-ray beam that passes through an object in order to create its images. While standard X-ray imaging techniques such as CT rely on a decrease of the beam’s intensity, in PCI the x-ray beam’s phase shift is not measured directly, but is transformed into variations in intensity, which then can be recorded. When applied to samples that consist of elements with low atomic numbers, PCI is more sensitive to density variations than conventional transmission-based Xray imaging, which leads to improved soft tissue contrast. HospiMedica International February-March/2018

Total-Body PET Creates New Patient Care Possibilities first-generation total-body positron emission tomography/computed tomography (PET/CT) scanner could revolutionize the understanding and treatment of disease, claims a new study. Under development at the University of California Davis (UCD, USA; www.ucd.edu), in collaboration with United Imaging Healthcare (Shanghai, China; www.united-imaging.com), the prototype total-body PET/CT scanner, called EXPLORER, will offer the ability to detect focal pathologies throughout the whole body at once, including cancer, infection, and inflammation, and at considerably lower levels of disease activity than currently possible. It will also reduce the time taken to scan the whole body by at least a factor of 10, leading to scan times that could be less than one minute. By covering the entire body at once, sensitivity is increased by a factor of ~40 for total-body imaging, or a factor of ~4-5 for imaging a single organ such as the brain or heart. Significant improvements in timing resolution could lead to even further sensitivity gains. According to the researchers, the combination with total-body PET could produce overall sensitivity gains of more than two orders of magnitude, when compared to existing state-of-the-art systems. The study was published in the January 2018 issue of the Journal of Nuclear Medicine (JNM). “One total-body PET scanner could take on the work load of threeto-four conventional PET scanners, and being able to receive imaging biomarkers from more distant distribution centers will minimize the need for costly in-house biomarker production,” said Terry Jones, DSc, clinical professor of diagnostic radiology at UCD. “As the impact of highsensitivity, total-body PET scanning becomes apparent, this will provide a major stimulus to physicists, chemists, and engineers to develop lower-cost detectors for total-body surveillance.” PET is a nuclear medicine imaging technique that produces a 3D image of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide tracer. Tracer concentrations within the body are then constructed in 3D by computer analysis. In modern PET-CT scanners, 3D imaging is often accomplished with the aid of a CT X-ray scan performed on the patient during the same session, in the same machine.

Image: The EXPLORER total-body PET/CT scanner (Photo courtesy of Martin Judenhofer /UCD).

Imaging Technique Shows Progress of Alzheimer’s yperspectral Raman imaging can help identify neuritic plaques and neurofibrillary tangles in people suffering from Alzheimer’s disease (AD), according to a new study. Researchers at the University of Twente (UT; Enschede, The Netherlands; www.utwente.nl), Paracelsus Medical University (Salzburg, Austria; www.pmu.ac.at), and other institutions evaluated frontal cortex and hippocampus samples from three brain donors and one control with AD, using hyperspectral Raman imaging in order to identify neural structures. The researchers used 12 30×30 μm unstained samples of brain tissue to generate data matrices of 64 × 64 pixels, in which different tissue components, including proteins, lipids, water, and β-sheets were imaged at 0.47 μm spatial resolution. Hierarchical cluster analysis was then performed to visualize regions with high Raman spectral similarity. The results showed that Raman images of proteins, lipids, water, and β-sheets matched classical brain morphology. Protein content was double, β-sheet content was X5.6 times, and Raman broadband autofluorescence was X2.4 times higher inside the plaques and tangles than in the surrounding tissue, while lipid content was equal. Broadband autofluorescence showed some correlation with protein content, and a better correlation with β-sheet content. The study was published on November 15, 2017, in Nature Scientific Reports. “Compared to MRI, PET and CT imaging, Raman is able to detect areas smaller than cells with very high precision. In this way, it can be a very valuable extra technique,” concluded senior author Cees Otto, PhD, of the Medical Cell Biophysics group at UT.

HospiMedica International February-March/2018

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MRI SYSTEM

DR SYSTEM

MinXray

Medonica

ARCOMA

The Integris features wireless communication and a built-in 19-inch touch screen computer/monitor. Durable and built to move, it features a high degree of customization and functions as a complete DR lab, making it ideal for clinics and hospital settings.

The Magvue uses a permanent magnet to generate 0.33T magnetic field. It provides positioning convenience for patient comfort, while other features such as remote coil identification, automatic table movement and remote patient handling offer user convenience.

The Precision features advanced applications such as auto-stitching and tomography to create an efficient workflow and maximize patient throughput. It combines auto-positioning with an ergonomic design to provide an optimal solution for all imaging needs.

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Novel MRI Technique Predicts Spinal Degeneration new magnetic resonance imaging (MRI) technique uses apparent diffusion coefficient (ADC) maps to assess water dynamics in the intervertebral disk and other spinal structures. Researchers at Irkutsk State Medical University (IRKSMU; Irkutsk, Russia; www.irksmu.com) and St. Joseph’s Hospital and Medical Center (Phoenix, AZ, USA; www.dignityhealth.org) conducted a study involving 100 consecutive patients admitted to the spinal surgery service in order to evaluate the utility of ADC maps generated from diffusion weighted (DWI) MRI in the assessment of patients with advanced degenerative lumbar spine disease. ADC values and characteristic maps were assessed in the regions of interest over different degenerative lumbar spinal pathologies. In all, the study included 452 lumbar vertebral segments. ADC map features were identified for protrusion, extrusion, and sequester types of lumbar disk herniation; spondylolisthesis; reactive Modic endplate changes; Pfirrmann grade of intervertebral disc degeneration; and compromised spinal nerves. The results showed compromised nerve roots had significantly higher mean ADC values than adjacent contralateral nerve roots. Compared to normal bone marrow, Modic I changes showed higher ADC values and Modic 2 changes showed lower ADC values, respectively. And ADC values correlated with Pfirrmann grading, but differed from herniated and non-herniated disks of matched Pfirrmann 3 and 4 grades. The study was published

on August 28, 2017, in PLOS One. “We’re improving our understanding of one of the most common maladies to affect humans, which is spinal disc degeneration,” said study author Mark Preul, PhD, of the St. Joseph’s Barrow Neurological Institute. “Imaging technology such as MRI ADC mapping will provide much greater and improved information to the physician treating patients with degenerated disc and other degenerative spine conditions.” “The imaging findings are being compared with the histology and biomarkers of disk degeneration that will eventually help to recognize and predict the disease earlier, and help to choose the best treatment option for each patient,” concluded lead author Evgenii Belykh, PhD, of IRKSMU. “The research initiative will image larger numbers of patients to confirm and investigate further applications for ADC mapping in the spine.” MRI is widely used for imaging evaluation of patients with low back pain. T1 and T2-weighted MRI sequences provide anatomical information regarding the soft tissues, including fat and water content, and are usually used for the assessment of the lumbar discovertebral complex, focusing on structural changes in the intervertebral disk and zygapophyseal joints, reactive vertebral bone marrow changes, location and extent of the disk material displacement, degree of the stenosis, and location and extent of nerve root compression.

Nano-CT Device Creates High-Resolution 3D X-Rays novel imaging device can produce images that approach the resolution of a scanning electron microscope, while also capturing structures under the surface. Under development at Munich Technical University (TUM; Germany; www.tum.de) and the University of Kassel (Germany; www. uni-kassel.de), the Nano-CT system is a table-top laboratory device and data processing pipeline that routinely and efficiently generates high-resolution three dimensional (3D) data at about 100 nm resolution of very small biological samples, without requiring synchrotron radiation optics. The researchers used the system to demonstrate the walking appendage of a Euperipatoides rowelli – the velvet worm – a representative of the Onychophora invertebrate group, which is considered pivotal for understanding animal evolution. Comparative analyses proved that nano-CT depicted the external morphology of the limb with an image quality similar to scanning electron microscopy (SEM), while simultaneously visualizing internal muscular structures at higher resolutions than confocal laser scanning mi-

croscopy, enabling the researchers to reveal hitherto unknown aspects of the Onychophoran limb musculature and enabling 3D reconstruction of individual muscle fibers. The study was published on October 3, 2017, in PNAS. “Our goal in the development of the Nano-CT system is not only to be able to investigate biological samples, such as the leg of the velvet worm; in the future, this technology will also make biomedical investigations possible,” said professor of biomedical physics Franz Pfeiffer, PhD, of TUM. “Thus, for example, we will be able to examine tissue samples to clarify whether or not a tumor is malignant. A non-destructive and three-dimensional image of the tissue with a resolution like that of the Nano-CT can also provide new insights into the microscopic development of widespread illnesses such as cancer.” “In contrast to arthropods, onychophorans do not have segmented limbs, as is also the case with their presumed common fossil ancestors,” said senior author Georg Mayer, PhD, of the department of zoology at the University of Kassel. HospiMedica International February-March/2018

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Medical Imaging

Optical Scintillation Detector Monitors Radiation Treatments new system provides diagnostic pinpoint accuracy measurement of the radiation treatment plan by verifying the dose delivered is consistent with the prescribed dose. The RadiaDyne (Houston, TX, USA; www.radiadyne.com) OARtrac system is a real-time in vivo dosimetry device system that uses disposable scintillating detectors during stereotactic body radiotherapy (SBRT) and intensity-modulated radiation therapy (IMRT) for prostate cancer treatment or brachytherapy. The system is based on plastic scintillation detector (PSD) probes connected to a duplex fiber-optical cable that transmits the PSD signals to a charge coupled device (CCD) camera that measures the scintillator output signal.

The optical measurement is converted to an electrical signal and displayed on a digital readout located in the control room of the linear accelerator treatment machine. Based on the continuous review of the accumulative dose data provided by the system, radiation oncologists can adjust subsequent treatment if and when required, thus allowing for a true adaptive radiation therapy protocol. The PSD sensor cable can be used up to five times on the same patient. “Radiation oncologists can now monitor multiple radiation delivery modalities within the same treatment center, as well as reduce overall treatment costs related to routine patient dose monitoring,” said John Isham, founder of RadiaDyne.

New MRI Techniques Help Predict Neuro Outcomes esearchers are using advanced Magnetic Resonance Imaging (MRI) techniques to help predict the neurological outcomes of patients that survive a cardiac arrest. The researchers used MRIDiffusion Tensor Imaging (DTI) and resting-state functional MRI (fMRI) to show the large-scale functional integration, or connectome, of the brain. The study included 46 patients who had suffered a cardiac arrest, and were in a coma, and was published online in the October 2017 issue of the journal Radiology by researchers from Johns Hopkins University School of Medicine (Baltimore, MD, www.hopkinsmedicine.org). The researchers assessed the functional connectivity of the brain of the patients and found that brain connectivity measurements could predict the long-term recovery potential of patients with brain damage related to a cardiac arrest they had experienced. The researchers concluded that by carrying out MRI-based measurements of the functional connections in the brain they could better predict long-term recovery for those patients who suffered from a neurological disability following a cardiac arrest. The results

also showed that connectivity measures could provide early markers of long-term recovery potential in such patients. Lead author of the study, Robert D. Stevens, MD, said, “This is game-changing information about what happens in the brains of people who suffer cardiac arrest. We realize that network architectures can be selectively disrupted in this setting.”

Proton Therapy Lowers Cancer Treatment Side Effects new study concludes that proton beam therapy (PBT) is as effective as photon radiation in pediatric patients with head and neck cancer, but with less impact on their quality of life. Researchers at the University of Pennsylvania (Penn; Philadelphia, USA; www.upenn.edu), the Children’s Hospital of Philadelphia (CHOP, PA, USA; www.chop.edu), and other institutions conducted a study involving 69 consecutive pediatric patients treated with PBT for head and neck malignancies between 2010 and 2016. Among the children, 50% had rhabdomyosarcoma, 7% were treated for Ewing sarcoma, and the remaining pediatric patients were treated for a variety of other cancers affecting the head and neck regions. Clinical and dosimetric data were abstracted from the medical record in order to identify acute toxicities and early outcomes, which were compared to historic photon radiation results. The researchers found that one year after treatment, 93% of patients were still alive, and 92% did not experience recurrence at their primary disease site. No patients suffered toxicities above grade 3 (out of 5), with the most severe toxicities being mucositis (4%), loss of appetite (22%) and difficulty swallowing (7%), significantly lower toxicity rates associated with photon radiation. The study was published on October 23, 2017, in Pediatric Blood and Cancer. “Protons may be an important tool in improving quality of life both during treatment and for years after for these young patients,” said senior author Christine Hill-Kayser, MD, chief of the pediatric radiation oncology service at Penn and an attending physician at CHOP. PBT is a precise form of radiotherapy that uses charged particles instead of x-rays to deliver a dose of radiotherapy for patients. It can be a more effective form of treatment than conventional radiotherapy because it directs the radiotherapy more precisely with minimal damage to surrounding tissue. Evidence is growing that protons can be effective in treating a number of cancers, in particular in children and young people with brain tumors, for whom PBT appears to produce fewer side effects such as secondary cancers, growth deformity, hearing loss, and learning difficulties.

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ELECTROSURGICAL DEVICE

LAPAROSCOPY TRAINER

ACEM

Heal Force

GERATI

The ACHD camera incorporates a 1/3-type HD CMOS image sensor boasting of approximately two million effective pixels. It also features multi-format video outputs from SD to Full HD, offering both system flexibility and high quality images.

The LS2000 is designed for loop electrosurgical excision procedure in gynecology. With up to 150 watts output, automatic current monitoring and compensation functions, it can perform high precision cutting and coagulation with lower thermal damage risk.

The PLATO provides round-the-clock essential training opportunities and does not require an electrical connection. Flat and foldable, it makes use of the built-in camera of any smart phone or a tablet, making it suitable for aspiring surgeons.

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Elastomeric Biomaterial Guards Against Incisional Hernia new study describes how a biodegradable polycarbonate elastomer (CC-DHA) can be used as a protective visceral barrier during abdominal laparotomy closure. Developed by researchers at Weill Cornell Medical Center (New York, NY, USA; www.weill.cornell.edu) and Cornell University (Cornell; Ithaca, NY, USA; www.cornell.edu), the CC-DHA, which is comprised of a polycarbonate cross-linked network of dihydroxyacetone, glycerol ethoxylate, and tri(ethylene glycol), undergoes a controlled solid-to-liquid phase transition following hydrolytic cleavage of the carbonate cross-linked network by ketone functionality of the dihydroxyacetone. The result is a rapidly degrading barrier that can be left in situ to facilitate abdominal fascial closure. Using a murine laparotomy model, the researchers successfully demonstrated the material provided a puncture resistant, biocompatible, and degradable matrix that underwent rapid dissolution within three hours, without evidence of toxicity or intra-abdominal scarring. According to the researchers, the unique characteristics make the biomaterial extremely useful as a physical barrier to prevent inadvertent bowel injury during fascial closure, with a potential for wider application across a wide range of surgical and medical applications. The study was published on May 31, 2017, in Acta Biomaterialia. “If all goes well, this flexible material might one day help surgeons more confidently and securely close abdominal incisions. I hope it will

lead to fewer incisional hernias,” said senior author Professor Jason Spector, MD, PhD, of the departments of plastic surgery and biomedical engineering. Secure closure of the fascial layers after entry into the peritoneal cavity is crucial to prevent incisional hernia, yet appropriate purchase of the tissue can be challenging due to the proximity of the underlying protuberant bowel, which may become punctured by the surgical needle or strangulated by the suture itself. Devices currently employed to provide visceral protection during abdominal closure, such as the metal malleable retractor and Glassman Visceral Retainer, are unable to provide complete protection, as they must be removed prior to complete closure. Image: A rapidly dissolving barrier could protect tissues during laparoscopic closure (Photo courtesy of Cornell University).

Obesity Not a Deterrent to Total Joint Replacement Surgery bese patients who underwent knee or hip total joint replacement (TJR) reported similar post-operative pain relief and improved function as normal-weight patients, according to a new study. Researchers at the Geisinger Health System (Danville, PA, USA; www.geisinger.org), the University of Massachusetts Medical School (UMMS; Worcester, USA; www.umassmed. edu), and other institutions collected data from a U.S. national sample of 2,040 patients who underwent total hip replacement (THR) and 2,964 who underwent total knee replacement (TKR) from May 2011 to March 2013. Pre- and post-operative function and pain were evaluated according to body mass index (BMI) status, de-

fined as under or of normal weight, overweight, obese, severely obese, or morbidly obese. The results revealed that while severely and morbidly obese patients had less postoperative functional gain than the other BMI groups following THR, and with greater obesity level associated with more pain at baseline, they also experienced greater postoperative pain relief six months after surgery, so that the average postoperative pain scores did not differ significantly among BMI groups. The study was published on July 19, 2017, in the Journal of Bone and Joint Surgery. “It’s challenging for a patient who is severely overweight and suffering in pain to exercise; often they just can’t do it. Our evidence showed that severe morbidly obese patients can benefit

almost equally as normal weight patients in pain relief and gains in physical function,” said lead author Wenjun Li, PhD, of UMMS. BMI is a value defined as the body mass divided by the square of the body height, and is universally expressed in units of kg/m2. It was developed as an attempt to quantify the amount of tissue mass (muscle, fat, and bone) in an individual, and then categorize that person as underweight, normal weight, overweight, or obese based on that value. However, there is some debate about where on the BMI scale the dividing lines between categories should be placed, and recent studies claim that other measures, such as waist-to-height ratio (WHtR) and body fat, are better predictors. HospiMedica International February-March/2018

Sensor-Enhanced Robot Enables Precision Spinal Surgery ugmented robotic technology provides a high-precision, sensorbased surgical device for spinal and neurosurgical interventions. Under development by researchers at the University of Bern (Switzerland; www.unibe.ch), Bern University Hospital (Inselspital; Switzerland; www.insel.ch), and the Swiss Center for Electronics and Microtechnology (CSEm; Neuchâtel, Switzerland; www.csem.ch), The sensor-enabled technology uses the complexity of vertebral anatomy as a map, allowing the robotic drill to sense the bone terrain. When combined with electromyography (EMG) neuro monitoring, the robot can avoid such obstacles as nerves and boundaries of the bone. Thicker bone, thinner bone, and nerves are sensed with a super-human, robotic perception and verified at high speed by matching it to relevant imaging information established prior to the procedure. EMG data is then used as a crosscheck control loop to give early warning on the proximity of nerve tissue and overall integration of surgical robotic system. Once positioning is confirmed, the robotic drill uses force-density pose estimation to allow neurosurgeons to accurately place pedicle screws perfectly and with precision in every patient, every time. “For the first time the neurosurgeon has real-time data on where the drilling instrument is during the procedure and the surgical robot acts with supreme accuracy, shutting down the drilling far sooner that a human operator could, thereby avoiding breakthrough or injury,” said Andreas Raabe, MD, of the department of neurosurgery at Inselspital. “This means potentially zero morbidity procedures with respect to pedicle screw misplacement. We see this as the future of spine surgery.” The main challenge of manual spine stabilization using pedicle screws is the uneven terrain of vertebral bone, since functional articulation of the spine is only made possible by the complex shape and bone density composition of the vertebrae. Drilling and positioning a screw into a highly variable part of the spine, whether manually or with image guidance technologies, fails around 15%, with screw missing the central part of the vertebrae and extending out of the bone, in many cases to irritate surrounding tissue or nerves.

Intrauterine Balloon Tamponade Improves Hemorrhage Control new study shows that using an intrauterine balloon is associated with a significantly lower need for invasive procedures for hemorrhage control in women following vaginal delivery. Researchers at Université de Versailles Saint-Quentin-en-Yvelines (UVSQ; France; www.uvsq.fr) conducted a retrospective cohort study that included 72,529 women who delivered a baby during 2011 and 2012 in 19 maternity units in two French perinatal networks; one that routinely used an intrauterine balloon tamponade for postpartum hemorrhage management (study cohort), and another that did not (control). Postpartum outcomes were assessed based on discharge abstract data from the French national medical information system. The results revealed that invasive procedures were assumed in 298 women, representing 4.1 per 1,000 deliveries. The cohort network had a significantly lower proportion of women with at least one invasive procedure (3/1,000), compared to the control network (5.1/1,000). The study perinatal network also had significantly lower use of arterial embolization for those who delivered vaginally. Risk of an invasive procedure remained significantly lower in the cohort network for women who delivered vaginally, but not for women who delivered by Cesarean section. The study was published on December 4, 2017, in Obstetrics & Gynecology. Postpartum hemorrhage is the leading direct cause of maternal death worldwide. Intrauterine balloon tamponade is a minimally invasive intervention that involves inserting a balloon device into the uterus and then incrementally filling it with liquid, which applies pressure to the uterus until the bleeding stops. Even when it cannot completely control severe postpartum hemorrhage, it can still serve a critical role by reducing blood loss until the woman can be transported to a facility with surgical management and other treatment options.

HospiMedica International February-March/2018

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PRODUCT NEWS CYSTOSCOPE

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SURGICAL TABLE

SUCTION PUMP

Richard Wolf

Merivaara

Spencer Italia

The MAMBA vision features a thin and flexible outer sheath with articulation through 210 degrees both up and down. It features two distally integrated LEDs that provide homogeneous illumination, along with six integrated SIM digital algorithms.

The Practo is designed with the widest range of posture possibilities and smart controls that help surgeons work more fluently. It comes with improved safe working load and width extenders, and is available in three models with a motorized leg sections option.

The Res-Q-Vac is an easy to use manual suction pump that is capable of generating a suction of -300 mm Hg by pressing the pedal with hand, knee or foot. It allows clearing of the patients' airways in a safe, quick and efficient manner during emergency situations.

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Anti-Gravity Treadmill Facilitates Knee Surgery Recuperation new study describes how a graduated return to running using an anti-gravity treadmill can enhance self-efficacy and subjective knee function. Researchers at the University of Kent (Canterbury, United Kingdom; www.kent.ac.uk) reported the case study of a 39-year-old healthy female endurance runner who suffered from a left knee femoral cartilage defect, for which she underwent arthroscopic microfracture surgical repair using bone marrow aspirate concentrate. Following surgery, an AlterG (Fremont, CA, USA; www.alterg.com) anti-gravity treadmill was used to manipulate loading during her graduated phased return to running over a period of eight weeks. During the study, self-efficacy was evaluated using the Self-Efficacy for Rehabilitation outcomes scale (SER) and the Knee Self-Efficacy Scale (K-SES). Subjective knee function was evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form (IKDC). The results showed improvements in SER (57%), K-SES

present (89%) and K-SES future (65%) self-efficacy domains. IKDC score increased from 62.1 to 86.2, a 39% increase. The study was published on June 8, 2017, in Physical Therapy in Sport. “This case report illustrates the importance of considering self-efficacy in rehabilitation after knee osteochondral surgery, and highlights the potential role for anti-gravity treadmills in enhancing self-efficacy and subjective knee function in preparation for a return to sport, “ concluded lead author Karen Hambly, PhD, and colleagues of the School of Sport and Exercise Sciences. “Devices like the anti-gravity treadmill enable walking or running without the full weight of the body, reducing the load on the joints in the lower limbs and bridging the gap between rehabilitation and return to sport.” The anti-gravity treadmill was originally invented by Robert Whalen, a biomechanics researcher at NASA Ames Research Center, to help astronauts train in space. The original de-

sign encloses a treadmill and the astronaut’s lower body in an airtight chamber; lowering the air pressure inside the chamber pushed the astronaut down, simulating gravity, allowing exercise at normal Earth weight. For Earthbound users, the technology is reversed to take the weight off of rehabilitation patients recovering from leg and foot injuries. Image: An antigravity treadmill can help knee surgery patients run again (Photo courtesy of Karen Hambly / University of Kent).

Brain Stimulation Reduces Spasticity after Spinal Cord Injury new study claims that excitatory intermittent theta burst stimulation (iTBS) is successful in reducing spasticity in patients with spinal cord injury (SCI). Researchers at Paracelsus Medical University (Salzburg, Austria; www.pmu.ac.at), the University of Verona (Italy; www.univr.it), and other institutions conducted a study to investigate if iTBS, a safe, noninvasive and well-tolerated protocol of excitatory repetitive transcranial magnetic stimulation (rTMS), is effective in modulating spasticity. The study included ten subjects with incomplete cervical or thoracic SCI. Five patients received 10 days of real or iTBS, and the remaining five received sham treatment. After two months, the sham group was switched to real iTBS and the study continued. The researchers measured motor-evoked potentials (MEP) in the soleus (calf muscle), during magnetic stimulation over the most responsive area of

the scalp. M-wave and H reflexes, which are measures of muscle contractions due to stimulation of the tibial nerve, were assessed for each subject, and an H/M amplitude ratio was determined. Modified Ashworth Scale (MAS) and the Spinal Cord Injury Assessment Tool for Spasticity (SCAT) were also compared before and after the stimulation protocols. The results showed that patients receiving real iTBS showed significant increased resting and active MEPs amplitude and a significant reduction of the H/M amplitude ratio. In addition, both MAS and SCAT scores were significantly reduced after treatment. The changes persisted up to one week after the end of the iTBS treatment, and were not observed under the sham-iTBS condition, suggesting that iTBS may be a promising therapeutic tool for spasticity in SCI patients. The study was published on June 6, 2017, in Restorative Neurology and Neuroscience. HospiMedica International February-March/2018

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Surgical Techniques

Data-Driven Digital Portal Advances Spine Surgery novel software platform delivers predictive modeling resources to drive intelligent strategic decisions and create personalized surgical implant solutions. The Medicrea (Neyron, France; www.medicrea.com) UNiD HUB software is intended for digital surgical planning in spine surgery in order to create a seamless communication channel between UNiD LAB biomedical engineers and surgeon users in order to deliver UNiD TEK patient-specific spinal implants, which are manufactured by the company through proprietary rod bending and three dimensional (3D) printing techniques. UNiD HUB also serves to enhance existing proprietary technology utilized by the Medicrea UNiD Adaptive Spine Intelligence (ASI) platform. The digital communication portal opened with the introduction of UNiD HUB creates a user-friendly environment for surgeons to identify tendencies and correlations, track and manage open cases in both snapshot and detailed views, access their complete patient history with postoperative analyses, and hold a dialogue with a dedicated biomedical engineer in real time. UNiD HUB was developed in desktop and mobile applications, and is accessible from medical offices as well as on the go. “This new generation of software will be more than a communication tool for surgeons; it will grant surgeons access to the same data analytics and machine learning technology that is curated by our data scientists to use the UNiD HUB as an unparalleled research engine and networking platform,” said Denys Sournac, President and CEO of Medicrea. “The UNiD HUB represents Medicrea’s ability to lead the spine industry with breakthrough innovations by offering a unique forward-thinking and holistic approach to personalized spinal surgery.” The UNiD TEK patient-specific spinal rod is pre-contoured and cus-

Aggressive Surgery Recommended For Early Stage Lung Cancer atients with early stage lung cancer live longer when they undergo a lobectomy rather than less extensive surgery or radiation treatment, according to a new study. Researchers at the University of California, San Diego (UCSD, USA; www.ucsd.edu) conducted a study to evaluate the comparative effectiveness of open surgery and stereotactic body radiation therapy (SBRT) in treating lung cancer, using the Veteran’s Affairs (VA) infrastructure system in order to identify 4,069 veterans with biopsy-proven clinical stage I non-small cell lung cancer (NSCLC) diagnosed between 2006 and 2015. The researchers compared cancer-specific survival among patients receiving lobectomy, sub-lobar resection, or SBRT. In all, 449 SBRT, 2,986 lobectomy, and 634 sub-lobar resection procedures were analyzed, revealing a higher immediate postprocedural mortality in the surgery groups compared with the SBRT group. On the other hand, the five-year incidence of cancer death was lowest in the lobectomy group at 23%, with the sub-lobar group at 32%, and SBRT patients at 45%; SBRT was also was associated with an overall 45% increased risk of cancer death, compared with lobectomy. The study was published on November 29, 2017, in Annals of Thoracic Surgery. “Our data suggest that the higher operative risks of surgery are more than offset by improved survival in the months and years after treatment, particularly for lobectomy. The more aggressively we treat early lung cancer, the better the outcome,” said lead author Alex Bryant, BSc, of the UCSD School of Medicine. Lobectomy is the removal of an entire lobe of the lung; sub-lobar resection is a less extensive operation that includes wedge and segmental resections; SBRT delivers very high doses of radiation over a short period of time (typically 1-2 weeks), precisely targeting the tumor. As of 2015, SBRT accounts for 19% of all NSCLC treatments, mainly for patients who are too sick to tolerate a major operation like lobectomy, which remains the standard treatment for early lung cancer in patients who can tolerate a major surgical procedure.

HospiMedica International February-March/2018

tomized using a reproducible industrial process that eliminates the intraoperative use of a bending device. The UNiD HUB platform helps the surgeons preoperatively plan and order customized rods to fit the specific spinal alignment needed prior to surgery, thus reducing the amount of time patients spend in the operating room, which also directly impacts infection rate and quality of recovery. The UNiD rods are available in two alloys (Titanium TA6V ELI or Cobalt Chromium), and two diameters (5.5 or 6 mm), matching global standards. The rods also fit into the PASS LP thoraco-lumbar fixation system, which also includes the UNiD anterior lumbar interbody fusion (ALIF) spine cages created with a three-dimensional (3D) printer. Specific software and advanced imaging are used to make the cages out of Poly Ether Ketone Ketone (PEKK) in order to reproduce the anatomic details of a patient’s vertebral endplates. Image: The UNiD HUB digital spinal surgery planning software (Photo courtesy of Medicrea).

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WOUND CLEANING SYSTEM

ENDOSCOPY SYSTEM

Dilon Technologies

Lifotronic Technology

SonoScape

The CoPilot VL+ is designed to help providers have the optimum view of the airway when placing breathing tubes. It features a larger, brighter, higher resolution display along with powerful LEDs, and its compact size makes it ideal for every medical setting.

The CareMaster removes exogenous stimuli using impulse cleaning and removes minor irritants and necrotic tissue using ultrasound cleaning. It uses negative pressure to automatically collect waste fluid and promotes primary healing of infected wounds.

The HD-350 is designed specifically for screening and diagnosis with a budget friendliness. It can meet the demands of many hospital and clinics, and help doctors improve their confidence and accuracy in patient diagnosis.

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Wound Retraction System Fights Surgical Infections n intuitive retraction system utilizes active cleansing technology to consistently and continuously clear harmful bacteria that may invade the incision during surgery. The Prescient Surgical (San Carlos, CA, USA; www.prescientsurgical.com) CleanCision wound retraction and protection system is a sterile, single-use irrigating wound device that integrates surgical retraction, wound barrier protection, and fluid delivery and removal to protect against surgical site infections (SSIs). The wound barrier protection part is made of a flexible, doublewalled sheath with an impermeable inner layer that protects wound edges from contamination. The same sheath provides integrated fluid delivery via gravitational feed to the wound edges through the permeable outer layer of the sheath. The wound retraction component is formed by attaching the doublewalled sheath to a fixed-diameter ring at the bottom, which is inserted into the abdominal cavity, and to an adjustable-diameter radial retraction ring at the top, which is designed to remain outside of the body and actuated to complete wound retraction. The excess irrigation fluid is removed through the bottom ring via connection to a standard vacuum suction mechanism. The CleanCision system has been approved by the U.S. Food and drug Administration (FDA). “We are initially focusing on abdominal surgery and particularly colorectal surgery, where the risk, frequency, and severity of surgical site infection is high and the need is acute,” said Jonathan Coe, co-founder, president, and CEO of Prescient Surgical. “Our team collaborated closely with leading hospitals in abdominal surgery to create a technology

platform and product that could be used in the full range of open and minimally invasive approaches utilized in their procedures.” “While infection control workflow and processes steadily improve year after year, the tools and technologies that should aid those efforts simply haven’t kept pace,” said Insoo Suh, MD, co-founder of Prescient Surgical. “A proactive approach to clearing contamination during surgery has the potential to better protect patients from infection, and help hospitals address the increased health care costs that result from surgical site infections, such as extended hospital stays, re-hospitalization, and rising infection rates that trigger penalties from CMS.” SSIs are an important source, and may even be the most frequent healthcare-associated infection (HAI) after asymptomatic bacteriuria, representing a high burden on patients and hospitals in terms of morbidity, mortality, prolonged length of hospital stay, and additional costs. Each year, approximately 500,000 surgical patients develop SSIs. Image: The CleanCision retraction system combines wound protection and irrigation (Photo courtesy of Prescient Surgical).

Active Robotic System Advances Orthopedic Surgery novel surgical system brings active robotic precision to total knee arthroplasty (TKA) and total hip arthroplasty (THA). The THINK Surgical (Fremont, CA, USA; http://thinksurgical.com) TSolution One Surgical System is based on an innovative robotic platform that enables a surgeon to create a patient’s personalized pre-surgical joint replacement plan using computerized tomography (CT)based three dimensional (3D) planning and an open-source implant library in order to achieve an optimized surgical plan. The TSolution One uses two revolutionary technologies that work in synergy to bring an exceptional degree of precision and accuracy to total joint replacement. The TPLAN 3D planning workstation is a computer system for preoperative planning with 3D modeling and simple point-and-click control. Pre-surgical planning begins, for example, when the TPLAN con-

verts the CT scan of the patient’s hip joint into a 3D surface model of the femur. The surgeon then selects an implant from the open library of legally-marketed implants and places it along the axes of the bone, with the help of anatomical landmarks, matching it to the patient’s anatomy so as to achieve optimal fit and alignment. During surgery, The TCAT computer assisted tool uses the pre-operative plan created by the surgeon for preparation of the bone cavity and joint surface, removing diseased bone and preparing the bone cavity and joint surface with sub-millimeter dimensional accuracy. The surgeon uses a digitizer to collect points and locate the exact position of the patient’s anatomy for precise surgical implementation using a range of specialized drill bits. If bone motion occurs, the system is halted, and the registration system helps the surgeon quickly recover bone position and resume surgery. HospiMedica International February-March/2018

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Surgical Techniques

Minimally Invasive Surgery Outcomes Beat Open Surgery Stats inimally invasive surgery (MIS) leads to more favorable 30-day postoperative outcomes when compared to traditional open surgery, according to a new study. Researchers at Henry Ford Hospital (Detroit, MI, USA; www. henryford.com) and Brigham and Women’s Hospital (Boston, MA, USA; www.brighamandwomens.org) conducted a study of 532,287 patients who underwent appendectomy, colectomy, inguinal hernia repair, hysterectomy, and prostatectomy, as identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program database. The researchers examined associations between surgery and 30-day postoperative outcomes, including complications, unplanned readmissions, hospital stay, and mortality. The results revealed that 53.8% of the patients underwent MIS for the five common surgical procedures. Within procedure-specific matched pairs, MIS was associated with significantly lower odds of Clavien–Dindo grade I–II, III, and IV complications, unplanned readmissions, and reduced hospital stay in four of the five procedures studied, with the exception of inguinal hernia repair. Odds of death were lower in patients undergoing MIS colectomy, hysterectomy, and appendectomy. The study was published on June 20, 2017, in BJS. “We expected some of the results, but the extent and consistency of the benefits associated with minimally-invasive surgery across four of the five studied procedures surprised us,” said lead author Akshay Sood, MD, of Henry Ford Hospital. “The findings also suggest that from an

Misoprostol Preferred in Preeclampsia Labor Induction new study concludes that low dose misoprostol is preferable for inducing labor in women with preeclampsia in low resource settings. Researchers at the University of Liverpool (United Kingdom; www. liv.ac.uk), Government Medical College (Nagpur, India; www. gmcnagpur.gov.in), and Gynuity Health Care (New York, NY, USA; www.gynuity.org) conducted an open-label, randomized trial in two public hospitals in Nagpur (India), involving 602 women who were randomly assigned to induction with misoprostol (302 women) or Foley catheterization (300 women), between Dec 20, 2013, and June 29, 2015. All women were at 20 weeks’ gestation or later with a live fetus, and required induced delivery due to preeclampsia or hypertension. The pregnant women received labor induction with either oral misoprostol (25 g every two hours for up to 12 hours), or via transcervical silicone Foley catheter; the catheter remained in place until active labor started, fell out, or when 12 hours had elapsed. If the catheter did not fall out within 12 hours, induction continued with artificial membrane rupture and oxytocin administered through a micro-drip gravity infusion set. The primary outcome was vaginal birth within 24 hours. The results showed that women in the misoprostol arm had a 10% higher rate of vaginal birth within 24 hours, and less need for caesarean section; they were also more satisfied with the outcome than those induced with the catheter method. Rates of uterine hyper-stimulation were low in both the misoprostol and Foley catheter groups, and neonatal deaths did not differ significantly between groups; 17 serious adverse events (3%) were reported during the study, including two stillbirths (both in the Foley catheter group), eight neonatal deaths, and five cases of neonatal morbidity. The study was published on June 28, 2017, in The Lancet. Misoprostol is commonly used for the prevention of NSAID-induced gastric ulcers by inhibiting the secretion of gastric acid by parietal cells. Misoprostol is also commonly used for labor induction by inducing uterine contractions and the ripening of the cervix. As such, it is also used either alone or in conjunction with other medications (such as methotrexate) for medical abortions, which are less invasive and more discreet than surgical abortions.

HospiMedica International February-March/2018

economic perspective, MIS may be more cost-effective than traditional open surgery, because complications and unplanned readmissions represent the major drivers of treatment costs.” MIS, which can be performed on both inpatient and outpatient basis, appeals to patients as it involves less blood loss, smaller surgical scars, shorter hospital stays, and less need for analgesics. A typical procedure is performed through several small incisions, using a range specialized surgical instruments, miniature cameras and fiber-optic light sources, and high definition (HD) monitors. In most cases, the incisions are up to 10 cm in length, instead of the 15-20 cm incision required by traditional surgery. Image: According to a new study, MIS shows better outcomes in most surgical procedures (Photo courtesy of Alamy).

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PACS SYSTEM

DRX RETROFIT SOLUTION

Sony

Medicatech

Carestream Health

The LMD-X310MD 4K delivers four times the resolution of HD for the true-to-life clarity that’s critical for seeing various nuances of color and detail. The display is considered ideal for general surgery, medical education and training.

The PACS offers medical 3D and color image desktop/web viewer with full-enhanced functionality such as measurements, annotations and rotations. The scalable system can be installed as stand-alone or can be integrated with any suite of applications.

The DRX-Transportable System/Lite is equipped with wireless tablet PC featuring a 12-inch touch screen. The tablet uses a virtual access point within the detector to display images as they are acquired and provides the user with complete control of the system.

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Patient Platform Provides Image-Sharing Functionality patient-centric imaging exchange platform enables healthcare facilities to securely distribute medical images and reports to patients via a native app. The Paxeramed (Newton, MA, USA; https://paxeramed.com) CareRad image exchange platform gives patients control over their magnetic resonance imaging (MRI) and computerized tomography (CT) scans, x-ray studies, and other medical images, right from their mobile phone. As a result, the need to burn CDs and DVDs is obviated, administrative tasks are streamlined, and patient satisfaction increased. CareRad also utilizes the highest security measures, and is designed to integrate with any picture archiving and communication system (PACS). Once verified, a patient can use the dedicated smartphone app to forward images from the imaging center to another clinician or facility. The patient controls the whole transaction, including granting permissions to the doctor or surgeon. A provider side companion application called CareRadMD allows attending radiologists to communicate directly with healthcare providers, thus solving potential communication issues when imaging results are needed urgently. Other features include assistance to find nearby clinics and hospitals; view care providers’ contact information and communicate with them via secure messaging; authorize family members to access medical data

through secure proxy settings; receive educational materials related to healthcare issues; and connect with wearable devices or input medical data manually. The CareRad and CareRadMD apps are available on the iTunes App store and on Google Play. Image: A novel image-sharing platform puts the patient in control (Photo courtesy of Paxeramed).

Digital Retinal Screening Reveals State of Health igital techniques and big data can provide an accurate picture of a person’s general medical condition by imaging the retina, claims a new study. Under development at the Medical University of Vienna (MedUni; Austria; www.meduniwien.ac.at), the automated digital retinal screening technique uses optical coherence tomography (OCT) technology to perform 40,000 scans of the retina within 1.2 seconds, with a total volume of 65 million voxels. The OCT data are then analyzed using automated algorithms generated on the basis of artificial intelligence (AI), revealing a range of information on the subject, such as age, gender, smoking habits, blood pressure, and diseases or susceptibility to diseases such as diabetes. According to the researchers, the innovative approach represents an important step towards better comprehensive care of the rapidly increasing number of diabetics, and that it might be possible in the future to also use OCT to detect diseases of some internal organs, such as the kidneys, or age-related problems and neurological diseases from a retina scan. Both the device and the AI algorithms were presented at the Ad-

vanced Retinal Therapy (ART) specialist conference, held during December 2017 in Vienna (Austria). “As a window into the condition of a person’s brain and vascular system, the retina offers huge insights into their life science data; not only about existing or potential diseases, but also about lifestyle,” said Ursula Schmidt-Erfurth, MD, head of the MedUni department of ophthalmology and optometry. “A large number of digital techniques are already being used in the management of eye conditions, always with the aim of improving standards of ophthalmological care. Digital retinal scanning is an additional revolutionary step in this direction.” OCT is based on low-coherence interferometry, typically employing near-infrared (NIR) light. The use of relatively long wavelength light allows it to penetrate into the scattering medium. Depending on the properties of the light source, OCT can achieve sub-micrometer resolution. OCT, being an echo imaging method, is similar to ultrasound imaging, but can image only 1-2 mm below the surface of biological tissue, as at greater depths the proportion of light that escapes without scattering is too small to be detected. HospiMedica International February-March/2018

Cloud Platform Facilitates Medical Image Sharing

Health IT I

n innovative image-sharing platform allows any doctor to easily send a medical image for instant review to any other doctor. The Anatomage (San Jose, CA, USA; www.anatomage.com) Cloud universal medical image sharing platform allows doctors to share medical images for instant review on any digital device by using a web browser-based three dimensional (3D) digital imaging and communications in medicine (DICOM) viewer, with no added software installation needed to view the image. Provided free to medical professionals for basic use, the Health Insurance Portability and Accountability Act (HIPAA)-compliant service obviates the need for CDs or USBs. Although originally designed in response to the growing number of specialists that utilize cone beam computerized tomography (CBCT) imaging, the service can now be used to share images from any imaging modality that uses DICOM as a standard format, such as magnetic resonance imaging (MRI). When used in conjunction with the company’s Invivo6 workstation software, Cloud enables users to rely on no other software tools or managing files. “The increased use of 3D CBCT scanners in dental, medical, and even NE DES W veterinary practices has resulted in IGN more patient 3D scans and the desire to collaborate with 3D images,” said David Skoff, business development manager of Anatomage. “For instance, an oral surgeon and orthodonWORLD’S MEDICAL PRODUCT MARKETPLACE tist need to view the same patient scan to develop their treatment plan together. The process of sending the scan between offices by CD or USB is SIGN UP slow and cumbersome, but is typical FOR FREE! because the file size is large and it requires dedicated viewing software.” “Anatomage Cloud solves both of these problems because it allows the doctor to send the case quickly and provides viewing capability on any device with a web browser-based 3D DICOM viewer,” added Mr. Skoff. “This technology enhances the speed and ease of collaboration for dental specialists, medical professionals, veterinarians, chiropractors, ENT specialists, and more. Anatomage Cloud opens the door to the most comprehensive network of medical and dental collaboration through 3D visualization.”

Image: A 3D CT scan visualized via the Anatomage Cloud platform (Photo courtesy of Anatomage).

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AI Platform Upgrades CT, Ultrasound, and Analytics Solutions E Healthcare (GE, Little Chalfont, United Kingdom; www. gehealthcare.com) and Nvidia (Santa Clara, CA, USA; www. nvidia.com) have announced a series of imaging equipment advances to be powered by Nvidia’s artificial intelligence (AI) computing platform. The collaboration between the two companies will accelerate a host deep learning solutions in order to design more sophisticated neural networks for healthcare and medical applications, ranging from real-time medical condition assessment, to point-of-care (POC) interventions, and even the use of predictive analytics for clinical decision-making. For patients, the partnership aims to drive lower radiation doses, speed up exam times, and provide a higher quality of medical imaging. The first device to benefit from the collaboration is the Revolution Frontier computed tomography (CT) system, which processes images twice as fast as its predecessor by using Nvidia’s AI computing platform. The increased processing power is expected to deliver better clinical outcomes in liver lesion detection and kidney lesion characterization, potentially reducing the need for unnecessary follow-ups, benefiting patients with compromised renal function, and reducing non-interpretable scans with the assistance of Gemstone Spectral Imaging Metal Artefact Reduction (GSI MAR). Another device that will benefit is the GE Healthcare Vivid E95 4D Ultrasound system, which will use the Nvidia graphics processing unit (GPU) to provide fast and accurate visualization and quantification

of ultrasound imaging while streamlining workflows across the cSound imaging platform. The Nvidia Quadro GPU will accelerate reconstruction and visualization of blood flow and improve two-dimensional (2D) and four-dimensional (4D) imaging for echo lab and interventional deployments. Modules of the new GE Healthcare Applied Intelligence analytics platform will also use Nvidia GPUs, the Nvidia CUDA parallel computing platform and application programming interface (API) model, and the NVIDIA GPU Cloud container registry to accelerate the creation, deployment, and consumption of deep learning algorithms in new healthcare analytic applications, which will be seamlessly integrated into various clinical and operational workflows. Image: The Nvidia Quadro GPU will bring AI to medical imaging devices (Photo courtesy of GE Healthcare).

Apple Watch Health Accessory Performs ECG Readings novel accessory for the Apple (Cupertino, Ca, USA; www. apple.com) Watch allows users to discreetly capture their electrocardiogram (ECG) anytime, anywhere, in order to quickly detect normal sinus heart rhythms and atrial fibrillation (AF). The AliveCor (San Francisco, CA, USA; www.alivecor.com) KardiaBand is based on a sensor built into a dedicated Apple Watch strap. The user first places a finger onto the sensor in the strap. It then performs a single point ECG to assess whether the electrical impulses that modulate cardiac contractions are firing properly. The resulting 30-second waveform is shown on the Apple Watch screen, after which the user can share it with their doctor as a PDF document. The system also includes the SmartRhythm machine learning algorithms, which sift through data gathered by Apple Watch’s sensors to monitor heart rate and activity. When SmartRhythm detects that heart rate and activity are out of synchronization, the device notifies users they should capture an ECG.

KardiaBand requires a subscription to the AliveCor Premium service for USD 99 a year, which includes SmartRhythm Apple Watch notifications; unlimited ECG recordings; automatic detection of AF or normal sinus rhythm; unlimited ability to send ECG readings via email; unlimited cloud history and reporting of all ECGs ever taken; weight and medication tracking; and a monthly paper report on readings taken each calendar month. The Apple Watch is a smartwatch with infrared (IR) and visible-light light-emitting diodes (LEDs) and photodiodes in a set of four rings built into the back, which are used to measure the wearer’s pulse. The watch also includes an accelerometer for tracking movement, and a linear actuator for haptic feedback. Integrated apps include many built-in health features in order to provide users a complete picture of physical and nutritional activity. Other features include beaming social messages, displaying maps, simplified apps, and, of course, telling the time. HospiMedica International February-March/2018

Industry News

Elekta and IBM Watson Health Alliance to Bring AI to Oncology lekta (Stockholm, Sweden; www.elekta.com) is collaborating with IBM Watson Health to offer Watson for Oncology with its cancer care solutions. Beginning in early 2018, Elekta will sell Watson for Oncology as a clinical decision support solution, paired within its digital cancer care solutions, including the MOSAIQ Oncology Information System. Elekta offers equipment and software for the treatment of cancer and brain disorders. Its treatment solutions and oncology informatics portfolios are designed to enhance the delivery of radiation therapy, radiosurgery and brachytherapy, and to drive cost efficiency in clinical workflows. Watson for Oncology was developed by IBM in collaboration with Memorial Sloan Kettering Cancer Center (MSK) in New York. It can summarize the key medical attributes of a patient and provide information to oncologists to assist them in delivering treatment options based on training from MSK oncologists. Watson for Oncology ranks treatment options based on peer reviewed studies curated by MSK and provides a large corpus of medical literature, drawing on more than 300 medical journals, over 200 textbooks, and close to 15 million pages of text for providing insights into different treatment options.

Report Identifies Challenges For Medical Device Manufacturers In Emerging Markets he emerging markets are expected to provide significant growth opportunities for manufacturers of medical devices due to their increasing importance in modern healthcare. In spite of the positive outlook for the emerging medical devices markets, manufacturers will need to overcome some challenges related to product quality, regulatory compliance, and data security, according to Infiniti Research (London, UK; www.infinitiresearch.com), a full service business intelligence and market research firm. Infiniti Research has identified the top five challenges that will be faced by medical device manufacturers in the emerging markets: Ensuring Product Quality: Manufacturers of medical devices will need to provide products of the highest quality in order to avoid recalls, which can have a negative impact on brand reputation as well as profitability. Ensuring product safety, security, and reliability will be extremely vital for medical device manufacturers to sustain in the highly competitive emerging markets. Regulatory Compliance and Government Support: Medical device manufacturers will need to strictly adhere to product safety standards and regulatory compliance. They will be required to consider the varying compliance and regulatory standards across countries in the emerging markets. Medical device manufacturers will also face the challenges of garnering government support for subsidized R&D, expediting approvals, tax and financial support, and favorable tax reimbursements. Localization of Medical Devices: Local manufacturers of medical devices in the emerging markets are more successful than multinational companies as they offer tailor-made products, which fulfill domestic needs. They usually undertake market research and leverage the benefits of local operations and a domestic sales force to bridge the gaps in the market. IoT Integration and Data Security: Medical device manufacturers also face a technical challenge in the form of Internet-of-Things (IoT) enabled medical devices and surgical instruments. Manufacturers of medical equipment are increasingly concerned about the best methods to collect, secure, and manage the vast amounts of sensitive data stored in a cloud-based infrastructure, as well as to prevent data theft and breaches. Cost of Product Development: The burgeoning cost of product development will also prove to be a major challenge for medical device manufacturers. In addition to technology and government regulations, medical service providers evaluate new products based on price as against factors such as patient experience.

HospiMedica International February-March/2018

Healthcare Augmented Reality And Virtual Reality Markets to Reach USD 5 Billion by 2023 he augmented reality (AR) and virtual reality (VR) in the healthcare market was valued at USD 769.2 million in 2017 and is expected to grow at a CAGR of 36.6% during the forecast period to reach USD 5 billion by 2023. The market growth will be driven by increasing penetration of connected devices in the healthcare sector, rising investment in healthcare AR and VR, and growing need to reduce healthcare costs. However, the lack of competence in the deployment of AR and VR solutions, and lack of expertise among medical practitioners to adopt new technologies are the major restraints for market growth. These are the latest findings of Research and Markets, (Dublin, Ireland; www. researchandmarkets.com), a global market research company. Growing interest among people in AR and VR is a key growth driver of patient-care management application in the market for AR and VR in healthcare. The increase in the use of AR and VR for therapies and rehabilitation is expected to drive the growth of AR and VR in healthcare market for patient-care management. The use of AR and VR in research and diagnostics laboratories is expected to help increase their efficiency by collecting samples and data from remote locations in real time. High- and medium-volume laboratories can use AR and VR to automate their testing processes and remotely monitor equipment. Research laboratories are also undertaking rigorous research work in the development of AR and VR. The increased interest in AR and VR among research labs is expected to drive the market for AR and VR in healthcare. Geographically, Asia Pacific has witnessed increased adoption of the latest technologies as most manufacturers of display panels are located in this region. Fitness management, patient care management, and pharmacy management are expected to contribute significantly to the growth of AR and VR in healthcare market in the Asia Pacific region. These applications hold huge growth potential for AR and VR players in the healthcare market due to increasing awareness among healthcare providers and rising adoption of new technologies in various industries, especially in China, India, and South Korea.

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APRIL 2018 Asia Health 2018. Apr 2-4; Singapore; www.medlabasia.com 14th Emirates Critical Care Conference. Apr 5-7; Dubai, United Arab Emirates; www.eccc-dubai.com Saudi Healthcare Exhibition 2018. Apr 15-17; Riyadh, Saudi Arabia; http://saudihealthcare-expo.com Southeast Asian Healthcare & Pharma Show 2018. Apr 17-19; Kuala Lumpur, Malaysia; www. abcex.com Medtec Europe 2018. Apr 17-19; Stuttgart, Germany; KOREA LAB 2018. Apr 17-20; Seoul, Korea; www.korealab.org Exposanita 2018. Apr 18-20; Bologna, Italy; www.exposanita.it/en EuroPrevent 2018. Apr 19-21; Ljubljana, Slovenia; www.escardio.org Frontiers in Cardiovascular Biology 2018. Apr 20-22; Vienna, Austria; www.escardio.org 2018 ARRS Annual Meeting. Apr 2227; Washington, DC, USA; www.arrs. org/AM18 IMTEC Oman 2018. Apr 24-26; Sultanate of Oman; www.medicaltourism fair.com Charing Cross Symposium 2018. Apr 24-27; London, UK; www.cxsymposium. com

MAY 2018 SEACare 2018 – Southeast-Asian Healthcare Show. May 4-16; Kuala

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International Calendar Africa Health 2018. May 29-31; Johannesburg, South Africa; www.africa healthexhibition.com EAES 2018 – European Association for Endoscopic Surgery and other Interventional Techniques. May 30-Jun 1; London, UK; http://eaes.eu

JUNE 2018 American Society of Clinical Oncology 2018 Annual Meeting. Jun 1-5; Chicago, IL, USA; http://am.asco.org EuroAnaesthesia 2018. Jun 2-4; Copenhagen, Denmark; http://euroanaesthesia2018.esahq.org EuroHeartCare 2018. Jun 7-9; Dublin, Ireland; www.escardio.org CARDIOSTIM 2018. Jun 20-23; Nice, France; www.cardiostim.com INAC 2018 – 4th International Neonatology Association Conference. Jun 22-24; Ghent, Belgium; http://2018. worldneonatology.com

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